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Why Emergency Medicine Teams shouldn't just Move on after a Patient Dies

Why Emergency Medicine Teams shouldn't just Move on after a Patient Dies
08/02/2017
statnews.com

statnews.com 

Kevin A., barely 20, lies bloody and broken on a gurney in my emergency department. He was ejected through the front windshield of his friend’s car as it rammed into a telephone pole. It’s hard to look at his ravaged face without feeling my own teeth breaking into pieces.

During the ambulance ride, his thready pulse vanished, if he ever had one. The medics couldn’t distinguish what they felt from what they wished they felt. Regardless, Kevin’s heart isn’t beating now. The trauma team cracks open his rib cage and sternum in search of blood filling the sac around the heart, or a hemorrhage from one of the large blood vessels. It’s always a last-ditch effort and rarely works.

As the time of death is called, a brief silence descends over the trauma room.

It’s broken by angry yells from the driver of the car. He’s in a trauma room across the hall, intoxicated, screaming at the staff, and ignorant to the tragic fates of his passenger-friends. The back-seat passenger is in another trauma room. She is likely to survive, but due to her injuries will likely lead a life very different from one of unbridled promise she possessed earlier that evening.

The team in Kevin’s room — doctors and nurses, techs and social workers — share looks without actually looking at one another. Our expressions hide feelings that range from sadness and grief to injustice and rage.

So much to process and make sense of, yet we don’t talk about it. Instead, we seek safe harbor in our respective duties and rituals. We document. We clean the body. We notify the organ bank. We rip off blood-streaked gowns and gloves and toss them into garbage bins. We snap a fresh sheet over Kevin’s body and brace for the families to arrive.

And we move on.

“That’s what we do,” the senior emergency medicine resident said to me the following night at the hospital. I’d confessed how the case had followed me home when I got off my shift. The resident admitted that he hadn’t slept well either. A nurse described being similarly haunted.

“But that’s what we do, right? Move on?”

I nodded. The nurse nodded. The resident nodded. But something felt wrong about those ready nods.

How can any sentient being move on after exposing a human heart that a short time ago pumped with life and promise? But moving on is embedded into emergency medicine practice. Simultaneously caring for a large number of patients, juggling the sick, the not so sick, and the needy. This feat involves handling a mix of complex workups, procedures, and conversations. There’s always too much to do and too little time. Focusing on any one activity for long means that other patients wait. We move on because desperation and efficiency demand that we do so.

This attitude isn’t without its perils. Moving on might be what we do, but that doesn’t make it right or healthy. Despite attempts at bravura, emergency medicine providers, along with other frontline specialists, burn precariously bright when it comes to depression and burnout. When physicians suffer, patients may suffer, too. When my emotional reserve drops, it means I have a limited supply of what my patients deserve — compassion, patience, and comfort with stories that unwind without direction.

Many factors have been posited as contributors to burnout in medicine. They include lack of control over the work environment, a disparity between personal values and the system, more time spent with electronic health records than with patients, and a sense of not making a difference, not to mention the ever-lengthening shadow of litigation.

There are also stressors specific to emergency medicine that place its practitioners at further risk for burnout, including the constant exposure to patients suffering from extreme physical and emotional trauma.

Add to this list the “it’s what we do” mental trap.

Sadly, the senseless death of a young man is a familiar story, another entry in the ledger of senseless deaths and tragedies that make up the ambient reality of work in a trauma center. Whether moving on is the product of this dulled resignation or the root of the problem, I can’t say. Regardless, Kevin’s death hit me in a vulnerable place. That a young man’s heart lay exposed and unprotected before me and I didn’t feel a chill caused me to shudder.

So did imagining tomorrow for the driver of the crash who, once he woke up, would face a lifelong hangover of sadness and regret.

The impulse to keep moving is natural and invested with purpose and pride. But what Kevin’s untimely death taught me is that it comes with a cost. A numb heart is hard to recognize until it begins to warm and nerve endings crackle to life. The ache throbbed with the gravity of it all — Kevin’s death, the trauma code, the lives of so many others irrevocably changed — and the realization that the nobility of the “it’s what we do” attitude often serves as easy cover for those crushing experiences that deserve to be recognized, not blindly endured.

I tell the emergency medicine resident that I screwed up. I should have brought the team together for a few minutes after we pronounced Kevin dead. Trauma centers have described “the pause,” a moment of silence after an unsuccessful resuscitation that honors the life that is now gone. But instead of a pause, maybe it should have been a complete stop. Such a gesture would not only honor Kevin and the other lives altered by this tragedy, but remind us all that such deaths are not normal, and we shouldn’t pretend otherwise.

Jay Baruch, M.D., is an associate professor of emergency medicine and director of the Scholarly Concentration Program in Medical Humanities and Ethics at the Warren Alpert Medical School of Brown University in Providence, R.I.

 

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